Chapter 7 Foot and Ankle issues

 7.1      Drop foot

“Foot drop is characterized by steppage  gait. When the person with foot drop walks, the foot slaps down onto the floor. To accommodate the toe drop, the patient may use a characteristic tiptoe walk on the opposite leg, raising the thigh excessively, as if walking upstairs, while letting the toe drop. This serves to raise the foot high enough to prevent the toe from dragging and prevents the slapping. Other gaits such as a wide outward leg swing (to avoid lifting the thigh excessively or to turn corners in the opposite direction of the affected limb) may also indicate foot drop.[1]

Adapted from http://en.wikipedia.org/wiki/Foot_drop

case 1:

      A young, somewhat cheerful, vibrant lady had complaint of severe headache. It had been debilitating. Her employer drove her to see me.  Upon exam, her muscles were tight over the entire body.    

Analysis and treatment:

Her neck and shoulder was very tight for sure. The headache was the result of tight neck and shoulder (Please refer to neck and shoulder problem section) which is easy to treat. I had done that numerous times. However, in such case, the result did not last for more than a few minutes. Turned out that that she was incapable of relaxing. Her body automatically tensed up. She was aware of such tendency. Whenever she was aware of her tenseness, she would relax which helped her symptom a little. But then she would get distracted and forgot to relax. Her body musculature then tensed up immediately.

Her past history interview revealed that she had had a major trauma. She was shot in the back 12 year earlier. The bullet scar was visible, about ¾ inches to the L-1 lumbar spine.  That gunshot paralyzed her legs for a long time.  Through her own will power, she managed to gain back full function for the left leg with some diminished sensation. The right leg was not as fortunate. This leg appeared to be about one third smaller than the left leg with severe diminished sensation. Worst of all, she could not flex her right foot.  Actually she was having a “drop foot” condition on the right. She walked by dragging her right foot! She depended on left foot to walk.  She did hide her gait rather well. When I asked her to flex her right foot, she could hardly flex the right foot, less than quarter of an inch maxes, trying as hard as she could master.  I could see the problem-that she was using her quad muscle to raise the foot. Her quad and calf muscles soon became  exhausted.

I used needles following my protocols to release the back and neck tension. Which was effective but her body overall remains quite tense. She does not have much feeling when needles were inserted on the legs, just pressure sensation. I proceeded to use electro acupuncture, between St36 and Sp9, GB 34 and S t41. I  added  Lv 3 and St 36 .  The result is non existence even with very strong needling technique. Only, a slight motion of the foot was observed in sync the rhythm of electrical pulsing. She still had no ability to flex the foot.

Turning point

I decided to remove the needles and instead using indirect moxibustion with smokeless moxa stick, applying to St36 which is the most power acupoint of YangMin meridian of the right leg.  I then asked the patient to flex the foot.  Amazingly, her flexing was improving bit by bit. Within 10 minutes, her foot flex’s range of motion wasabout 70% of normal people. She just could not believe it. It was quite exciting.

She came in the following week for another treatment. Her right foot was still doing very well. She did not have headache either. For the first time in 12 years, she could walk like normal people.

Historical anecdote

This is so interesting because only one point St 36 was needed. Hers is a case of treating “Wei Syndrome” or foot atrophy syndrome in TCM. This is intriguing. About 2000 years ago, according to Yellow Emperor Cannon of Internal Medicine, Yellow Emperor asked his royal court minister, Mr. Qi Bo, who he consult for medical questions, why it was said  in the literature that “ With  Wei Syndrome, treat  only the Yang Min meridian”.  Qi Bo replied that although Yang Min is the main meridian of choice, more meridians are involved because any one of the five Yin organs can produce to Wei syndrome. This answer became the standard answer of treating “Wei Syndrome” since that time.

In truth, it was not the correct answer. What Mr. Qi Bo did was to change the definition of the “Wei Syndrome”. The prevailing definition of” Wei syndrome” at the time of Yellow Emperor’s question was “feet atrophied incapable to walk”. Mr. Qi Bo changed the definition entirely. He used the term to indicate the atrophic symptoms of the body. His defined Wei syndrome as various body atrophy conditions caused by prolonged inflammation which exhausted Visceral Yin.  With this definition, Yang Min meridian is not particularly useful. This incident caused problems for TCM doctors for years to come.

For thousands years on ward, every TCM doctors on record would quote Yellow Emperor’s question, treated it as a statement and then just like Qi Bo simply dodged the question and explained why the statement in Yellow Emperor’s inquiry is not quite correct.

7.2       Acute incident caused “wei’ syndrom

Coincidentally, a month later, an old patient of mine came. He was a young man in his early 30’s. He was working hard in his friend orchard with heavy lifting and accidently lost balance and slipped. Afterwards, he had certain sore muscle in the low back and hip. His right foot became “heavy” which refused to go away for more than a week.  He had difficult working because of heavy foot which was also weak. Flexing the foot took some effort.

I tried couple methods treating the leg and low back that was caused his fall. The improvement on the foot was minimal. Then, I repeat the moxibustion procedure exactly like the previous case. The patient could literally feel the “heaviness” diminished. With three more treatments, the foot problem was eliminated.

Comment: Therefore, ancient doctors before Nei Jing’s publication were right about “Wei syndrome”, that “only Yang Min meridian is needed for treatment of Wei Syndrome”. There is one nagging question remains; that in the young lady’s case, I did initially use Yang Min, St 36 with electro acupuncture without success. Only through moxibustion was I able to achieve the desired result. The plausible answer is that there is significant Qi deficiency in her case due to long term nonuse. Much more Qi and Yang raising was required to get it going than electro acupuncture can offer.

7.3      case 2

In year 2000, I treated another case of drop foot. The patient was a man in his early 40’s. He had an incident and had surgery on the right tibia muscle group. The doctor who did the operation was quite skillful, yet he lost control of his right foot. He had developed drop foot.  I used electro acupuncture on the Yang Min meridian. With ach pulse, I could see his right foot flexing in sync with electrical pulse. It took a couple months to finish the treatment on once a weekly basis. In a few months he was able to regain the ability to flex the foot. No moxibustion was used.

Reference literature:

It is interesting to see other researchers also have similar experience about “drop foot”. Although more than Yang Min meridian was utilized in this following study.

“TREATMENT OF PERONEAL NEUROPATHY BY ACUPUNCTURE

                                             : A CASE REPORT  by Puo-Hsien Le1, Ching-Hsien Chang 1,2

1School of Traditional Chinese Medicine of Chang Gung University, Tao-Yuan, Taiwan Department of TCM, 2.Chang Gung Memorial Hospital, Keelung Branch, Keelung, Taiwan

                           ( Received 29th December 2008, accepted 27th February 2009 )

     "Foot drop is a deficit in turning the ankle to dorsiflexion due to the weakness of anterior compartment muscle. The patient with drop foot may use a characteristic hip hiking, steppage gait, tip-toe walk and foot slapping down to accommodate the toe drop. To prevent tumble, the ankle-foot orthotic are commonly used for the patient of peroneal neuropathy of cause unknown in Western medicine. From Traditional Chinese medicine's point of view, drop foot belongs to "leg flaccidity".

In this article, a case of drop foot received acupuncture treatment. The acupuncture points used were ST36, GB34, Jian Xia, SP6, and LV3. Among these acupuncture points, ST36 and Jian Xia were strengthened with electro stimulation. For this case, acupuncture treatment was effective.

Key words: peroneal neuropathy, drop foot, leg flaccidity”

Adapted from  J Chin Med 20(1,2): 79-85, 2009


Ankle problems

Most of the ankle problems come from injury.  Small injury like sprained ankle happens very often. Missed a step or have a fall and ankle would be messed up , painful, swollen, unable to walk.

As long as the bones are not broken and tendons not torn, sprained ankle is very easy to treat.  So, make sure the bones are not broken. Then,

First, warmed up the ankle, then, needle these points: LI 4 and LI11.  While moving the needle to get Qi, have the patient stretch the affected ankle. The pain should start to dissipate. Especially when the patient came in with swollen ankle, make sure to use the heat lamp to heat up the area first. Many people came in with cold swollen ankle after the sprain because they had been using ice to treat the ankle after the incident.  As long as the ankle remained icy, the swelling will remain. Heat is the best way to reduce the swelling.

With minor sprained ankle, the problem should be resolved with such treatment. If the sprain is more severe or lasted longer before getting treatment, some additional manual manipulation will accelerate the healing. The best way will be to perform isometric muscle stretching at the ankle.  

One day, we were walking along the Miramar Lake, I heard a boy biker crying his heart out. He was about 7 years old. He had his right shoe entangled in the hind wheel.  So the foot was hurting bad with any movement. His parents came over and tried to assure him, encourage him to be tough to no avail. I went over and grabbed his forearm with thumb on LI 11 and asked him to move the ankle. His father asked him whether it is hurting. After initial hesitation, he moved his foot and said no. Everything appeared as normal as before. He stopped crying. I walked away. It took about 3 minutes in all.

In this days and age, you should not do that without first ask for permission. I did not ask because of laziness, I did not want to answer a lot of question. It would have taken much longer to answer question then actually treat this boy. It might not even happen if the parents objected.

The same treatment is equally applicable to all other ankle pain. But if the ankle structure is altered, then, no assurance can be made for permanent fix. Once I had a male patient who had fusion of bones at the right ankle because of an accident that shattered the ankle bones.  He would come in and had had acupuncture, got pain relieve as well as increased flexibility of the affected ankle.  The pain, however, never totally disappeared. 

There are many other ways to treat the sprained ankle with good results. My method is by no means the only one. One famous acupuncturist Dr. Wei-Chieh Young liked to use a point called Xiao Jie which is on the thena eminence(pad of the palm). He claimed that its effect on sprang ankle is immediate. I suppose it is true as the point elicit a strong Qi. It may not be comfortable for patient though, so I have not used it myself.

Foot  pain:  Plantar fasciitis, heel pain

The first time I treated heel pain was with an early 30 year old  lady who loved to play base ball. She injured her heel in a game and her right heel became painful with weight. I first use heat lamp to warm up her foot, applied Zheng Gu Sui( a liniment for bone setting, muscle injury) and then use electro acupuncture, using Kd 3 and Kd6 for about 30 minutes. After about 6 times, the pain totally disappeared and she resumed her sport. I still do this way from time to time. But my emphasis have shifted to the calf.  As the calf is the source of the problem.

I would pay attention to the Lv 7, L8 and the surrounding muscles of the soleus.  Spasmed muscles can be felt around Knee area. Then I would apply both acupuncture needle as well as moxibustion to reduce the spasm, to move the stagnated Qi. Sometimes UB 47, 48 may have to be needled as well. Sometimes Kd 3, K5, K6 are added to increase the effect. The results are quite satisfactory. I apply the same method to people with complaint of plantar fasciitis as well as people complained of arch pain. The results are also immediate and good. My good friend Devatara up  in the Marin county , http://marinorientalmedicine.com/home/devatara-holman/  claimed to use Kd3 and UB60 with strong stimulation to treat plantar fasciitis with great result. This just indicate that there are more than one way to skin a cat( just joking).  Moving the stagnated Qi and the problem is resolved.